Has your child had a scoliosis examination by an approved scoliosis determination procedure clinic? If so, who performed the exam?

Please describe your child in your own words:

List any additional comments, questions, or concerns:

Parents' General Health Survey

Please check any health conditions or habits listed below that you may have, or that may be affecting you or your spouse:

Mother

Father

Both

Neither

Alcohol use

Anemia

Anxiety

Arthritis

Asthma

Backaches

Cancer

Depression

Diabetes

Diet

Digestive Problems

Dizziness

Exercise

Fatigue

Headaches

Heart Trouble

High Blood Pressure

Nervousness

Neuritis

Numbness

Sinus Trouble

Tobacco use

Please describe any of the health issues above, or others, affecting either you or your spouse:

Financial Responsibility

PLEASE NOTE:Dr. Laura Nunno does not participate with insurance companies. If you have out-of-network benefits, you can submit to your insurance for reimbursement.

I understand that all payments are due at the time of service and I agree to be financially responsible for any and all charges incurred. Should collection efforts be necessary, a 15% interest charge will be added to the balance due. I am liable for any cost incurred by Holistic Health Center in collection efforts.

Check below to indicate you have read the terms regarding financial responsibility. *

I have read and agree to these terms.

Appointment Policy

Please respect the time of our Doctor, Massage Therapists, and those on the waiting list by

giving at least 24 hours notice when cancelling.

The full session fee will be charged for no-shows and last minute cancellations.

Notice of Privacy Practices

Federal law requires Holistic Health Center of Cromwell to notify patients regarding our Privacy Practices and policies. A copy of our Policies is prominently displayed in our waiting room, available for all patients to reference and keep at any given time. Any revisions made to our Policies will be updated accordingly. A copy of our Policies may be made available upon request.

Federal Law requires Holistic Health Center of Cromwell to retain any and all signatures, forms and patient information obtained and documented for a minimum of seven (7) years.

Please check below to indicate that you have read this Notice of Privacy Practices

I have read the Notice of Privacy Policy

Informed Consent to Chiropractic Treatment of a Minor

As a patient, you have the right to be informed about the condition of your health and the recommended care and treatment plan to be provided so that you may make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks, and alternatives.

THE NATURE OF THE CHIROPRACTIC ADJUSTMENT

Chiropractic is a science and art which concerns itself with the relationship between the spine (the structure) and the Central Nervous System (the function), as that relationship may affect the restoration and preservation of your health. Health is a state of optimal physical, mental, and social well-being, not merely the absence of sickness or disease.

One disturbance to the Central Nervous System is called a vertebral subluxation. This occurs when one or more of the 24 vertebra in the spinal column become misaligned and/ or do not move properly. This causes alteration of nerve function and interference. This may result in pain and dysfunction or may be entirely asymptomatic.

The Doctor will use her hands or a mechanical device upon your body in such a way as to move your joints. That may cause an audible "POP" or "CLICK" much as you have experienced when you "crack" your knuckles. You may feel or sense movement. Additionally, other procedures such as thermotherapy, cold therapy, kinesiology, or other rehabilitative measures may be included.

THE MATERIAL RISKS INHERENT IN CHIROPRACTIC ADJUSTMENT

As with any health care procedure, there are certain complications which may arise during a chiropractic adjustment. Rarely, those complications may include: fractures, disc injuries, dislocations or muscle strain, Homer's syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment.

THE PROBABILITY OF THOSE RISKS OCCURRING

Fractures are rare occurrences and generally result from some underlying weakness of the bone, which we check for during your consultation, examination, and x-ray. The likelihood of these or other complications are generally described as "rare." If we encounter non-chiropractic or unusual findings, we will advise you of those findings and refer you to the appropriate health care professional.

Stroke has been the subject of tremendous disagreement within and without the profession, with one prominent authority saying that there is at most, a one-in-a-million chance of such an outcome. Since even that remote amount of risk should be avoided, we employ tests in our examination which are designed to identify if you may be susceptible to that kind of injury. The other complication are generally described as "rare."

ANCILLARY TREATMENT

In addition to chiropractic adjustments (manipulation), you may receive supportive therapies which will further assist in the management of your condition. While the risk of complication is low, there is a possibility of side effects such as burns, soreness, skin irritation, etc. Some of the additional treatments which may be used include heat therapy, cold therapy, massage therapy, and kinesiology.

Overuse of Over-the-Counter medications may produce undesirable side effects. If complete rest is impractical, premature return to work and household chores may aggravate the condition and extend the recovery time. The probability of such complications arising is dependent upon the patient's general health, severity of the patient's discomfort, the patient's personal tolerance of pain and self-discipline in not abusing the medication. Professional literature describes highly undesirable effects from long term use of Over-the-Counter medications.

Prescription muscle relaxants and pain-killers can also produce undesirable effects and dependence. The risk of such complications arising is dependent upon the patient's general health, severity of the patient's discomfort, the patient's personal tolerance of pain, self-discipline in not abusing the medication, and being under the supervision of a medical professional. Such medications generally entail very significant risks, some with rather high probabilities.

Hospitalization in conjunction with other care bears the additional risks of exposure to communicable disease, iatrogenic (doctor induced) mishap, and expense.

The risk inherent in surgery includes adverse reaction to anesthesia, iatrogenic (doctor induced) mishap, all the of hospitalization and an extended convalescent period. The probability of those risks occurring varies according to many factors.

THE RISKS OF REMAINING UNTREATED

Remaining untreated allows the formation of adhesions and reduces mobility which sets up a pain reaction further reducing mobility. Over time, this process may complicate treatment, making it more difficult and less effective the longer it is postponed. The probability that non-treatment will complicate a later rehabilitation is very high.

Please check below to indicate you have read the Informed Consent to Chiropractic Treatment of a Minor *

I have read the Informed Consent to the Treatment of a Minor.

Signature and Submission

<label>Your signature below indicates that you have read the Privacy Policy and are aware that a copy may be made available upon request. Additionally, you acknowledge that all of your questions regarding the doctor’s objective pertaining to your child's care in this office have been answered to your complete satisfaction, </label><label>understanding the benefits, risks, and alternatives of chiropractic care. </label>

<label>I have read and fully understand the above statements and would like to proceed forward with undergoing Chiropractic Treatment for my child. </label><label>I give my consent to Dr. Laura Nunno to provide chiropractic care to my child and </label><label>authorize the use of therapies administered by her assistant.</label>

Name of Child: *

Name of Parent or Guardian Authorizing Consent: *

Signature of Parent or Guardian Authorizing Consent:

You may use your mouse or finger to sign in the box above. Otherwise, you may sign this document at your appointment. Clear

Date (in-office use):

A photocopy of this agreement shall be considered as effective as the original.